Provider Demographics
NPI:1679798672
Name:WALL, JON (DC)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:
Last Name:WALL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4275 HARLAN ST
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-5119
Mailing Address - Country:US
Mailing Address - Phone:303-940-7167
Mailing Address - Fax:303-940-7258
Practice Address - Street 1:4275 HARLAN ST
Practice Address - Street 2:
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-5119
Practice Address - Country:US
Practice Address - Phone:303-940-7167
Practice Address - Fax:303-940-7258
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4777111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor